Most doctors fall into one of two categories: the smaller, who are excessively concerned with their health and regard each bodily sensation as the harbinger of serious disease, and the larger, who neglect it and ignore their symptoms altogether.
I belong to the latter. When I was a young man, for instance, I failed to recognise the symptoms of pneumonia and ignored them until I could hardly breathe. For me, doctors treated illness; they did not suffer from it themselves.
Even more difficult for many doctors is illness among their close relatives. How far should they interfere with diagnosis and treatment, at the risk of antagonising their colleagues? If they interfere, they might be regarded as difficult and obstructive; if they do not, they may overlook serious and even life-threatening mistakes.
A doctor recounts her experience in a recent edition of the New England Journal of Medicine. Her aged father collapsed at home while she happened to be there; he had recently had a quadruple bypass operation. His blood pressure had fallen dramatically.
At the hospital he was diagnosed with dehydration and given intravenous fluids. For a time his blood pressure improved and he felt better. Then his blood pressure dropped again. His daughter called a nurse who increased the fluids and for some reason switched off the alarm of the blood pressure monitor. Then she left.
When her father’s blood pressure dropped yet again, his doctor daughter went to the nursing station to inform the medical team. There she was more or less cold-shouldered, and because she did not want to appear one of those “difficult” relatives who seem to think that their loved one is the only patient the hospital has to look after, she did not insist. After all, doctors and nurses have many subtle or unconscious (and sometimes not so subtle or unconscious) ways of wreaking revenge on those whom they consider to have caused them unnecessary grief.
The medical team had overlooked one of the most obvious causes of loss of blood pressure in this case, namely internal haemorrhage. The patient was on anticoagulants after his cardiac surgery, and such a complication is not uncommon. His daughter decided to examine him herself by means of a rectal examination and found that he was indeed bleeding intestinally.
Schopenhauer would have enjoyed the spectacle of grand rounds in academic hospitals: his theory that people argue for victory more than for truth would have found confirmation there.
In grand rounds a physician presents a complex or enigmatic case to the other physicians of the hospital, who then discuss it in detail. The ostensible purpose is to teach, learn and sometimes to enquire; but such human desires as to show off, to appear more-learned-than-thou, and to appear brilliant are often much in evidence. I once worked in a hospital where an ancient and celebrated physician, who had had more diseases, albeit rare and obscure ones, named after him than any other physician in history, attended such rounds until well into his nineties. Once he had spoken he would ostentatiously turn off his hearing aid, the entire matter having been settled to his satisfaction by his own opinion.
The New England Journal of Medicine carries each week a case report from the Massachusetts General Hospital, presented on a grand round. Generally speaking they record a triumph of diagnosis and often of treatment, somewhat like a Sherlock Holmes story. The more obscure the diagnosis the more brilliant appears the solution, seemingly reached effortlessly by the teamwork of clinicians and pathologists. One cannot help but wonder, sometimes, what has been left out. Certainly the patient’s experience doesn’t get much of a look in.
Recently there was a case reported in the journal that brought to mind the old saying of Victorian surgeons, “the operation was a success, but the patient died.” It concerned a fifty-three year old woman who suffered from persistent redness of the skin and enlargement of the lymph nodes. She was susceptible to infections for which she had repeatedly been admitted to hospital (not the Massachusetts General) and treated with antibiotics.
Even non-hypochondriacs such as I sometimes worry fleetingly about their health when, having reached a certain age, some of their friends and acquaintances fall foul of a disease, namely (in this case) cancer of the prostate. But my anxiety does not last long and so far I have managed successfully to resist all attempts by my medical colleagues to measure my prostate specific antigen (PSA). I want to have as little to do with doctors as possible, other than socially of course, and there is nothing quite like a high PSA level to provoke doctors’ interference in a man’s life.
Would this interference, though, prolong my life if I allowed it to take place? A recent paper in the New England Journal of Medicine starts optimistically and ends pessimistically. It draws attention to the fact that mortality from prostate cancer has fallen drastically and attributes this to improvement both in early diagnosis of the cancer by means of screening and of treatment once diagnosed.
The body of the paper, however, is less sanguine. First 18,880 elderly men were divided into those who were given finasteride, a drug that was hoped would prevent cancer, and those given placebo. Some years later it was discovered that finasteride did indeed reduce the numbers of patients who developed cancer, in fact by nearly a third.
So far so good: but this is not the end of the story. Unfortunately, prostate cancer is a very variable disease such that, while some men die of it, many more men die with it than of it. And while finasteride seems to have prevented many low-grade cancers, those that would not have killed the men in any case, it seems also to have increased both the number and proportion of the more serious kind.
The major medical journals of the world receive far more papers than they can ever publish, and so it is rather surprising when dull, trivial or bad work appears in them. This must mean either that the editors of the journals, like Homer, sometimes nod, or that the general standard of the work submitted for publication is lower than one might hope or suppose.
A recent paper in the New England Journal of Medicine, entitled “Glucose Levels and Risk of Dementia,” by no fewer than fourteen authors, is a case in point. They repeatedly measured the blood glucose levels of 2067 people aged on average 76 at the start of the study, followed them up for a median length of 6.8 years, and correlated the levels with the patient’s chances of developing dementia.
It was already known that diabetics are at increased risk of developing dementia, not surprisingly in view of the damage that diabetes does to small blood vessels in the brain. But the authors of the paper put forward the hypothesis that higher levels of glucose even in non-diabetics would increase the risk of developing dementia.
They indeed found that non-diabetic patients with a blood sugar level of 115 milligrams per decilitre were more likely to develop dementia than those with a level of 100 milligrams. However, the extra chance, 1.18 times, though statistically significant, was so small that its significance in any other sense must be doubted. Generally speaking, epidemiological surveys which find such small differences are not of much value from the point of view of elucidation of the causation of diseases. If you trawled through a hundred factors – coffee consumption, number of begonias in the garden, subscription to a newspaper, etc. – you would probably find five such factors with odds rations as large (or small).
For most of my life I have had no difficulty in sleeping, rather in staying awake. But whether because of a physiological ageing process, or of a guilty conscience aware of a life of cumulative sin, I now experience periods of insomnia. Occasionally I do what I once swore as a young man never to do: I take sleeping tablets.
My favourite, to the exclusion of all others, is Zolpidem (Ambien). It does not leave me feeling groggy, as do other hypnotics, but rather as near to daisy-freshness as I ever feel early in the morning. Imagine my alarm, then, when I saw an article in a recent New England Journal of Medicine that suggested that the drug of my choice might make me a dangerous driver the following day.
Zolpidem is short-acting, which means that it is metabolised and cleared from the body quickly. Some people therefore find that they wake in the middle of the night when they have taken it (previous studies suggest that Zolpidem’s main advantage over placebo is in getting people off to sleep quickly). Having woken in the night, and finding difficulty in returning to sleep, some people are tempted to take more of the drug. Indeed, the manufacturers – the largest company listed on the French stock exchange – have thoughtfully manufactured a lower-dose pill for precisely this situation.
But simulated driving tests done on people after they have woken in the morning having taken Zolpidem demonstrate that they perform less well than people who have taken nothing. This is so even when people claim to feel no after-effects of the drug at all: in other words, they are not the best judges of whether or not they suffer such after-effects. The commonly-heard refrain, principally from middle-class hypochondriacs, that “I know my body” is not true in all, perhaps in many circumstances.
However, the article does not address certain important questions concerning the effect on Zolpidem on driving the following day. The first is that while Zolpidem may reduce performance on simulated driving tests, it is known that insomnia itself does likewise. So the question is not whether Zolpidem affects driving tests, but whether it affects driving tests among those who suffer from insomnia and who take it. In such circumstances, it is conceivable that it improves performance.
When doctors knew nothing and could do even less (if actively harming patients with their treatment counts as doing less than nothing), they hid their ignorance and therapeutic impotence by the use of impressive-sounding Latin terminology. Even when they spoke in the vernacular, they did their best to be incomprehensible, and generally succeeded. Portentousness was then a substitute for prowess.
Doctors are still inclined to use impressive-sounding words for the same purpose: or at any rate, so their critics say. Idiopathic is a learned way of saying that the cause of a disease is unknown; and when a disease is said to be multifactorial in causation, it is an implicit avowal of ignorance: for diseases should at least have necessary causes if doctors can claim to understand them.
Actually, most diseases are multifactorial: necessary conditions of causation in medicine are common, while sufficient conditions are rare. For example, the presence of the tubercle bacillus is a necessary condition for the development of tuberculosis, but not sufficient. Many are the people who are infected who do not get the disease.
An ill-understood condition that is thought nevertheless to be bacterial in origin is noma, or cancrum oris. This is a horrible disease that starts as an infected gum and then eats away a large part of the face, killing the patient or leaving him deformed for life. It now affects mainly children in Africa, but it once occurred in Europe and America and was common in the victims of German concentration camps during the Second World War.
Its cause is unknown, unless extreme poverty and malnutrition can be accepted as causes. Nevertheless, these are an insufficient explanation of the disease because, even in severely impoverished conditions, most people do not get it.
A Swiss group, working in a confined area of Niger, a Sahelian country that was once a French colony and that supplies the uranium from which France generates three quarters of its electricity, tried to find the cause of noma, that is to say a bacterially necessary precondition for its development, by comparing 82 children who suffered from it with over 300 matched control who did not. In summary, they failed to do so as have others before them, though certainly not for lack of trying. Their report of their efforts appears in a recent edition of The Lancet.
In private health-care systems, rationing of health care is by price; in public health care it is by waiting lists and administrative fiat. Both have their defenders, usually ferocious and bitterly opposed, but the fact remains that there are some treatments that have to be rationed however much money is available for health care: as when, for example, there are more people needing organ transplants than there are organs to be transplanted. Few people would be entirely happy to allocate organs merely to the highest bidder.
A recent article in the New England Journal of Medicine tackles the problem of allocation of lung transplants. A system was in place in the United States that excluded children under 12 years of age from receiving adult lungs as transplants, an exclusion that parents of a child with cystic fibrosis challenged in the courts. The problem for children under the age of 12 requiring lung transplants is that there are very few child donors, so in effect the system discriminated against them.
The reason for the exclusion was that most children for whom lung transplants are considered have cystic fibrosis, a condition for which the results of such transplants are equivocal given the constantly improving medical treatment of the disease. Moreover, children are especially liable to complications from the procedure, though these can be partially overcome by using not whole adult lungs for transplant but only resected lobes of them.
The American system of allocation of lungs for transplant into adults takes into account various factors, such as years of potential benefit from transplant, the imminence of death without transplant, the statistical chance of success of transplant, and so forth. Ability to pay does not come into it; in other words it is a socialized system, but there is a mechanism of appeal for those relegated to low priority which the more educated and wealthier are better able to take advantage of. No explicit judgment is made about the relative social or economic worth of the individual, however, for that way madness, or at least extreme nastiness, lies. And the authors of the article think that, on the whole, the system works well, for it seems to stand to reason that those who would benefit most should go to the top of the waiting list.
I once had a small transplant dilemma of my own…
Doctors are often appalled by their patients’ unhealthy habits, as much for aesthetic as for health reasons. They are also irritated by the refractory nature of those habits and the failure of patients to do anything about them even when repeatedly advised to do so. Such repetition serves a purpose, however. Doctors may not be able to cure their patients, but they can at least make them feel guilty. To do so relieves the doctor’s feelings.
Now that Type II diabetes – that used to be called maturity-onset in the days before children began to get it – has reached epidemic proportions, the scope for medical lifestyle badgering has increased enormously. But does it do any good?
The results of a very prolonged trial in America have just been published in the New England Journal of Medicine. More than 5000 fat Type II diabetics aged between 45 and 75 were randomly allocated to normal treatment and standard advice, on the one hand, and (sinister phrase) “intensive lifestyle intervention” on the other. The investigators ended the trial after most patients had participated in it for about ten years. Something called “futility analysis” revealed that prolongation of the trial was unlikely to produce positive results.
There is more rejoicing in the chambers of malpractice lawyers over one missed diagnosis than over ninety-nine dangerous, unnecessary and expensive investigations. It is therefore unsurprising that doctors are particularly anxious not to miss pulmonary embolus, a clot in the pulmonary arteries, which has been called a silent killer. There are several factors that predispose to PE, as it is known, among them age, a recent operation or having sat for a long time in a confined space. A friend of mine collapsed with a PE at home one day, and it was then that his polycythaemia rubra vera, a chronic overproduction of red cells, was diagnosed.
If PE can kill you, and if there is an effective treatment, it might seem that an improvement in the ability to detect it is to be welcomed. But, as is often the case in medicine, matters are a little more complex than they seem. As a recent article in the British Medical Journal put it:
If all pulmonary emboli caused important harm or death if untreated, finding more small clots would be an unqualified advance. However, there is evidence that some small clots do not need treatment…
And while new technology allows more small clots to be detected that would not have been detected by older methods, it does not give any guidance as to which of them should be treated. Since treatment (with anticoagulants) is itself not without risk, it is possible that the increased detection of small clots does more harm than good.
In the 8 years after the introduction of a new technique called multidetector CT pulmonary angiography, the rate of pulmonary embolus in the U.S. rose by 80 percent, from 62.1 to 112.3 per 100,000 adults. Part of the problem was that the new equipment, being very expensive to install, had to be used to justify its purchase. The result was many more PEs.
Treatment made no great advances in those years, and the overall rate of death from PE in the United States remained more of less constant. However, the fatality rate of detected PEs fell greatly, from 12.3 to 7.8 percent, suggesting that most of the PEs that were now being detected that would not previously have been detected were harmless.
Shakespeare, on the whole, was in favor of sleep – at least if the opinions of his characters are any guide to his own opinion. “He that sleeps feels not the toothache,” says the Gaoler in Cymbeline. Sleep, says Macbeth:
… knits up the ravell’d sleave of care
The death of each day’s life, sore labour’s bath,
Balm of hurt minds, great nature’s second course,
Chief nourisher in life’s feast.
By contrast, not to sleep is a torment. Shakespeare must have known insomnia, for in Sonnet XXVII he says:
Weary with toil, I haste me to my bed…
But then begins the journey in my head…
And keeps my drooping eyelids open wide,
Looking on darkness which the blind do see.
Shakespeare also knew that “there’s meaning in thy snores,” though perhaps not the meaning that doctors now attach to them. They often mean obstructive sleep apnea (OSA), when sleep, which should be “death’s counterfeit,” becomes death’s possible harbinger, in the form of heart attacks and strokes.
According to a recent article in the New England Journal of Medicine, between a fifth and a quarter of the American population suffer from OSA, and this poses a risk, whose magnitude is not precisely known, to patients undergoing surgical procedures. The reason the magnitude is not precisely known is that it is difficult to control for obesity: not all people who are fat have OSA, and not all people who have OSA are fat, but there is a strong correlation, almost certainly a causative one. What the authors of the article call “the epidemic” of OSA – yet another epidemic of a non-contagious risk factor – is really an “epidemic” of obesity. A higher proportion of patients undergoing surgery than in the rest of the population have OSA: not surprisingly, 80 percent of patients being operated on for their obesity have it. All in all, perhaps 10 million operations are performed in America annually on people with OSA.
Resistance to antibiotics is often described by neo-pagans as Mother Nature’s vengeance on Man for having had the temerity to interfere in her natural biological processes. According to the neo-pagans, this vengeance has left Man (deservedly) worse off than if he had never discovered antibiotics at all. I do not see the logic of this.
There is no doubt, however, that bacterial resistance to antibiotics is a serious problem worldwide. It is particularly serious in hospitals, where patients may pick up infections that they never had before admission. Many patients die from these infections, which may be of epidemic proportions.
The most important such infection is MRSA, methicillin-resistant Staphylococcus aureus. (Methicillin is a semi-artificial penicillin that was developed when the Staphylococcus first became resistant to ordinary penicillin, and soon met with resistance itself.) MRSA accounts for most post-surgical infections; the proportion of patients infected by it is often taken in research as a measure of a hospital’s hygiene.
An important paper in a recent edition of the New England Journal of Medicine compares various strategies for reducing the spread of MRSA in intensive care units, a common place for patients to become infected.
The method of control usually employed is to screen patients for MRSA on admission to the ICU and to institute special precautions such as isolation and barrier nursing if they test positive. The authors compared this method with attempts by means of antibacterial products at “decolonization” of those who tested positive, and similar “decolonization” practiced on every patient admitted to an ICU irrespective of whether or not he tested positive for MRSA.
Everyone who needs an operation (which eventually will include most of us) wants to be assured that it will be carried out in the best and safest conditions possible. All operations are serious for those having them; a minor operation, as the British physician George Pickering once put it, is an operation carried out on someone else.
Most people with the time or ability to search for the best hospitals, surgeons, etc., will not think of considering the day of the week on which the operation will be performed as a factor of safety. It has long been known that emergency operations done at night or on the weekends have worse results than those done during the day on weekdays; but what about routine or planned operations, those (the great majority) that can be done at the surgeon’s and hospital’s leisure, as it were?
A huge statistical study done in Britain and recently published in the British Medical Journal examined the 30 day death rates after all non-emergency operations performed between 2008 and 2011 (except day cases) according to the day on which the procedure was performed.
There were in total 27,582 deaths after 4,133,345 operations, a raw rate of 6.7 per 1000: a figure that by itself would have astonished our forebears, who were used to, and took as inevitable, death rates at least a hundred times higher.
What the researchers found was that people who underwent an operation on Fridays had a death rate 44 percent higher than those who underwent an operation on Mondays, while those who underwent an operation on the weekend had a death rate 82 percent higher.
When I was in my mid-twenties I developed heart failure on a flight to India. It was caused by viral myocarditis, and I found the whole experience interesting rather than alarming because I was still at an age when I thought I could not possibly die. Neither did it occur to me to request medical assistance: I had some insight into the helplessness of doctors in such situations.
A couple of years later I accompanied a madman on a flight back to his own country. His main symptom was a desire to kill himself by jumping out of high windows: not the ideal airline passenger, you might have thought. In my pocket I had a syringe ready with tranquillizer with which to jab him if he became difficult. It was all arranged very casually, but in the event nothing untoward happened.
We are better organized now, of course, as a paper in a recent edition of the New England Journal of Medicine shows. The authors collected data on the medical emergencies that occurred among roughly 10 percent of airline passengers worldwide between January 2008 and October 2010.
It is often said that flying is the safest means of transportation, and it does not seem to be medically very hazardous either. There was one emergency every 604 flights, and one per 62,500 passengers. Moreover, most of the emergencies turned out to be trivial or minor; only 7.3 percent – that is to say, 875 of 11,920 cases – resulted in diversion of the aircraft. Of course, 875 flights is a lot relative to most people’s lifetime, but it was 875 of 7,198,116 flights.
The most common symptom was fainting or feeling faint, followed by breathlessness and then nausea or vomiting. There were 30 deaths on board and 6 shortly after landing. The age of the oldest passenger to have suffered an emergency in flight was 100 (he didn’t die, though, and lived to fly another day).
Sometimes what is not said is more eloquent than what is. The implicit often has a more powerful effect on the imagination than the explicit; as Emily Dickinson put it, “Success in Circuit lies.” A recent article in the New England Journal of Medicine about Hepatitis C was eloquent in its omissions.
Hepatitis C is a virus infection which for many years causes no symptoms but which often goes on to produce chronic liver disease, cirrhosis, and cancer. About 85 percent of people infected with the virus develop chronic liver disease.
The article in the NEJM is titled “Hepatitis C in the United States.” The authors provide an estimate of the number of people infected with the virus: between 3.2 and 3.5 million.
The infection can now be treated so as to prevent its long-term consequences. Unfortunately, the treatment is expensive: about $70,000 per head for a full course, according to the authors. If every person who tested positive for the virus were treated, the cost would therefore be between $224,000,000,000 and $245,000,000,000. That is some stimulus to the economy!
The cost of treatment might come down (or, of course, go up, as new and costlier treatments are discovered). Not everyone who is infected needs treatment. Perhaps a vaccine will be developed and the problem in effect will go away. For the moment, though, we must deal with the silent epidemic – as the assistant secretary for health, Howard Koh, called it – with the tools now available to us.
Simple scientific questions require simple scientific answers; doctors want unequivocal guidance to their practice so that they do not fumble in the dark. But it is easier to ask questions than to answer them, as two papers published in the same week in the New England Journal of Medicine and the Journal of the American Medical Association attest.
The question asked by the two papers was the optimum level of oxygenation in the blood of pre-term infants. In the past it was rather naively supposed that if oxygen were necessary, then more of it must be better; but premature infants who were exposed to high levels of oxygen developed a condition known as retinopathy of prematurity, often leaving them blind or severely impaired visually.
The two trials, one from Britain, Australia and New Zealand, and the other from the United States, Canada, Argentina, Finland, Germany and Israel, sought to establish whether a higher or lower level of oxygen saturation of the blood was better for infants born very prematurely. The results were different, if not quite diametrically opposed.
The first trial found that babies treated so that their blood oxygen saturation was higher had a lower death rate at 36 weeks than those treated so that their levels were lower. 15.9 percent in the high-saturation group died compared with 23.1 per cent in the lower. You would have to treat 14 babies with the high oxygen saturation to save life more than treating them at the lower level.
Not long ago I bought a book, published in 1922, titled Syphilis of the Innocent. Needless to say, the title implied a corollary: for if syphilis could be contracted by the innocent (as, for example, in the congenital form of the disease), it could also be contracted by the guilty.
In general, however, physicians do not inquire after the morals of their patients, except in so far as those morals have immediate pathological consequences. They do not refuse to treat patients because they find them disgusting, because they find them unappealing, because they are appalled by the way they choose to live. They try to treat them as they find them; they may inform, but they do not reprehend.
However, in practice things are sometimes more complex than this ecumenical generosity of spirit might suggest. According to an article in a recent edition of the New England Journal of Medicine, some doctors have been turning away patients on the grounds that they were too fat (one physician suggested that she did so because, ridiculously, she feared for the safety of her staff once the patients weighed more than 200 pounds), or that their children have gone unimmunized. Is such discrimination by physicians legitimate or illegitimate, legally or morally speaking? Is there not a danger that physicians may hide behind pseudo-medical justifications to express their personal prejudices or to coerce patients into doing what the physicians think is good for them?
Does practice really make perfect? Does it even lead to improvement? One feels instinctively that it should, that the more experience a physician has, the better for the patient. Much of the skill of diagnosis is pattern-recognition rather than complex intellectual detection, and it follows that the longer a physician has been at it, the quicker he will recognize what is wrong with his patients. He has experience of more cases than younger doctors to guide him.
But the practice of medicine is more than mere diagnosis. It often requires manual dexterity as well, and the ability to assimilate new information as advances are made. These may decline rather than improve with age. Too young a doctor is inexperienced; too old a doctor is past it.
A recent paper, whose first author comes from the Orwellianly named Department of Veterans’ Affairs Center for Health Equity Research and Promotion, examined the relationship between the years of an obstetrician’s experience and the rate of complications the women under his care experienced during childbirth. The authors examined the records of 6,705,311 deliveries by 5,175 obstetricians in Florida and New York. No one, I think, would criticize the authors for the smallness of their sample.
They examined the rate of serious complications such as infection, haemorrhage, thrombosis, and tear during or after delivery, divided by obstetrician according to his number of years of post-training experience. Reassuringly, and perhaps not surprisingly, experience reduced the number of such complications decade after decade. The rate of complications was 15 percent in the first ten years after residency; it declined by about 2 percent to 13 percent in the first decade thereafter, by about 1 percent in the subsequent decade to 12 percent, and by half a percent in the next. In other words, improvement continued, but less quickly as the obstetricians became more experienced; the authors appear not to have continued their study to the age at which the rate of complications started to rise again (if indeed there is such an age).
There was a time in my country when, among other unpleasant duties, the prison doctor was required to assess prisoners for their fitness for execution. Needless to say, not much attention was paid in medical school to this particular skill: the physician was on his own because in those days there were no such things as official guidelines. The rough and ready rule was that a man was fit to be executed if he knew that he was to be executed and why. It was the death-penalty equivalent of informed consent to surgery.
One of the last British executioners, Albert Pierrepoint, who hanged about 600 people, wrote in his memoirs that he was often asked if people struggled on their way to the gallows. He replied that he had known only one do so; to which he added, by way of explanation, “And he was a foreigner.” However, foreign nationality was not in itself a contraindication to execution. Pierrepoint was one of the executioners at Nuremberg.
An article in a recent edition of the New England Journal of Medicine draws attention to the ethical and practical dilemmas of American physicians asked to assess people for fitness to carry concealed weapons. Again this is not a skill taught in medical schools. No firm criteria, beyond those of common sense (which have not been validated by research), have been laid down. It seems obvious that people with paranoid personalities or psychoses, gross depression or mania, those who take cocaine, amphetamines, or other stimulants, and alcoholics should be refused permission to carry concealed weapons. But many of those conditions (if taking cocaine can properly be called a condition) are easy to conceal or difficult to detect. How far is the doctor to go in attempting to detect them? Interestingly, or curiously, the authors do not mention hair or blood tests, which could certainly help the doctor detect drug and alcohol abuse.
Pain is obviously one of the most important symptoms with which doctors deal, but measuring its severity objectively is difficult. Some people turn a twinge into agony, while others raise not a murmur in the last extremities of torture. And it is universally accepted that a person’s psychological state or disposition has a profound effect on his perception of pain.
Philosophers, indeed, have used the phenomenon of pain to debate what seemed to them an important question, namely whether there were such things as private languages or inner states inaccessible to others.
Clever experiments reported in a recent issue of the New England Journal of Medicine offer the hope, perhaps illusory, that brain imaging techniques might one day distinguish between real and severe pain on the one hand from exaggerated or false pain on the other (people may exaggerate or lie about pain for a variety of reasons).
Having recently returned from Madrid, I confess that I saw little evidence of the Mediterranean diet being consumed there (apart, that is, from the red wine): though, of course, Madrid is in the middle of the peninsula, far from the Mediterranean. Perhaps things are different on the coast. Nevertheless, at over 80 years, Spain has one of the highest life expectancies in the world.
Is this because of the much-vaunted Mediterranean diet? Spanish research recently reported in the New England Journal of Medicine provides some – but not very much – support for the healthiness of that diet.
The researchers divided 7000 people aged between 55 and 80 at risk of heart attack or stroke because they smoked or had type 2 diabetes into three dietary groups. One group (the control) was given dietary advice concerning what they should eat; the two other two groups were cajoled by intensive training sessions into eating a Mediterranean diet, supplemented respectively by extra olive oil or nuts, supplied to them free of charge.
They were then followed up for nearly five years, to find which group suffered from the most (or the least) heart attacks and strokes. The authors, of whom there were 18, concluded:
Among persons at high cardiovascular risk, a Mediterranean diet supplemented with extra-virgin olive oil or nuts reduced the incidence of major cardiovascular events.
The authors found that the diets reduced the risk of the subjects suffering a heart attack or stroke by about 30 percent. Put another way, 3 cardiovascular events were prevented by the diet per thousand patient years. You could put it yet another way, though the authors chose not to do so: 100 people would have to have stuck to the diet for 10 years for three of them to avoid a stroke or a heart attack. This result was statistically significant, which is to say that it was unlikely to have come about by chance alone, but was it significant in any other way?
The unexamined life, said Socrates, is not worth living; but sometimes I wonder whether the too-closely examined life is not worth living either, for examination uncovers dilemmas where none existed before.
Two articles in a recent edition of the New England Journal of Medicine ask the question of whether employers should, or have the right to, refuse to employ smokers, as increasing numbers do in the 21 states that permit such discrimination against them.
As is by now no secret, smokers are more likely to suffer from many types of illness than non-smokers, and their health insurance is therefore considerably more expensive than that of non-smokers. They impose costs on their employers which weigh upon all workers, smokers or not. (The authors do not take into account that smokers not only contribute to taxes by their habit but, by dying early, reduce pension costs.)
The authors worry that refusal to hire smokers would be discriminatory against people of lower social class, since it is among the latter that smoking is most prevalent. I am not sure that this is right: the majority of people in all social classes now do not smoke, while people who apply for jobs at any particular level are likely to be of the same social class. Except in the case where there is only one applicant for a job, then, it is likely that there will always be an applicant of any given social class who does not smoke. The discrimination remains against smokers, therefore, and not by proxy against members of lower social class.
Twenty-seven years ago I found what seemed to be the only functioning storm-drain in Tanzania, in East Africa, and fell down it, severely injuring a knee in the process. The journey to the mission hospital in the back of a pick-up truck over sixty miles of rutted laterite road was one of the more agonising experiences of my life.
I had an arthroscopy when I returned home several weeks later — I could not even hobble until then — and the orthopaedic surgeon told me that unless I did physical therapy every day for a very long time it was inevitable that I should be crippled by arthritis within twenty years.
It was equally inevitable that I would not do physical therapy every day for a long time; and here I am, twenty-seven years later, without so much as a twinge from my knee. My faith in the predictive powers of orthopaedic surgeons has been somewhat dented.
That was why I read with interest a paper in a recent edition of the New England Journal of Medicine comparing physical therapy with surgery for meniscal tears in the knees of people with osteoarthritis. To cut a long story short, there was no difference in outcome, an important finding, since 465,000 people undergo operations for precisely this situation every year in the United States alone.
Actually, the uselessness of operation had been established before — the uselessness from the patients’ point of view, that is. Two previous trials had compared real with sham operations, and with no operations at all, and found no difference in the outcome two years later. One might suppose that, in the light of these findings, the 465,000 operations still performed annually constituted something of a scandal.
The clinical trial reported in the NEJM is, like all such trials, not definitive. The follow-up period was only 6 months, relatively few patients were recruited to it, and some patients initially allocated to physical therapy had an operation nonetheless for reasons that are not entirely clear. Moreover, the trial is only that of operation versus physical therapy; strictly speaking, there should also be a comparison with patients who had no treatment at all.
The Duke of Wellington, surveying his soldiers before the Battle of Waterloo, famously said that he did not know what they did to the enemy, but by God they frightened him.
No one thought in those days of the psychological effect upon the soldiers of witnessing so much violence (more than 30,000 were killed during the battle, about one in six of those who took part in it); nor could anyone have done so if he had thought of it. But it is now accepted wisdom that active military service leads men subsequently to commit crimes of violence, though the reasons for this are unknown.
A recent paper in The Lancet examined the association of military service and subsequent crimes of violence, which turned out to be much weaker than suspected. The authors examined the criminal records of 8,280 British soldiers who had served in Iraq and Afghanistan with that of 4,080 of those who had not. When controlled for such factors as age, level of education, pre-service record of violent offenses, rank, and length of service, there was no significant difference in the criminal records of those who had served in Iraq and Afghanistan and those who had not.
When, however, those who were deployed in a combat role were compared with those who had not been so deployed, it was found that the former had higher levels of violent offending as measured by their criminal records. Interestingly, however, those who were involved in actual fighting had considerably higher prior levels of violent offending than those not so involved, suggesting that more aggressive types either volunteered or were selected for combat service. Somewhat alarmingly, nearly half of soldiers involved in the fighting had criminal records for violence.
For a long time doctors were subject to contradictory imperatives with regard to AIDS. On the one hand they were enjoined to treat it as they would treat any other disease, without animadversion on the way in which the patient had caught it; on the other hand they had, before testing for the presence of HIV, to seek special permission of the patient and to ensure that he or she had had counselling before the test was taken – quite unlike the testing for any other disease, syphilis for example. So AIDS was at the same time a disease like any other and also in a completely different category from all other diseases.
It cannot be said that pre-test counseling is universally popular among patients. There was an Australian clinic that famously offered the test with “guaranteed no counseling” and it did not lack for clients. For quite a number of years, however, HIV-test counselling has provided a living for the kind of people who like to hover around the edges of human catastrophe.
However, the recommendation by the United States Preventive Services Task Force (USPSTF), reported in an article in a recent edition of the New England Journal of Medicine, that henceforth the screening of adults for HIV infection should be routine will, if adopted, put paid to all such pre-test counseling. One cannot counsel scores or hundreds of millions of people.
Seven years ago the USPSTF came to a different conclusion on the question of screening for HIV, believing that the benefits were insufficient to recommend it. Since then, however, evidence has accumulated that treating people early in the course of their infection not only prolongs their life but reduces spread of the infection.